intracranial hemorrhage - ucsdspinwarp.ucsd.edu/neuroweb/ppt/hemorrhage.pdf · brain hemorrhage mr...
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Intracranial Hemorrhage
John R. Hesselink, M.D.
Department of Radiology
University of California
San Diego
Intracranial Hemorrhage
Non-traumatic
Hypertension
Aneurysm
AV Malformation
Other
Other causes: bleeding into tumor, hypocoagulable state,
hemorrhagic infarction and iatrogenic
36%
11%
17%
36%
Intracerebral Hemorrhage
High density mass
Evolution depends on size
Perihematoma edema
Enhancement of perimeter
CT Features
Evolution of
Hematomas
Gomori et al, Diag Imag, 1985
Oxyhemoglobin
Deoxyhemoglobin
Methemoglobin
Intact RBC
Macrophage laden with hemosiderin
RBC Lysis
Hemosiderin
Edema &
Ischemia
Brain Hemorrhage
MR Signal Intensities
Time
High <12 hours
Low 1-3 days
Low
High
3-7 days
7+ days
Low
High
14+ days
14+ days
High 1-14 days
STAGE T1WI
Iso
Iso
High
High
Iso
Iso
Low
Oxy Hgb Hyperacute
Deoxy Hgb in RBC
Hemosiderin
Hemichromes
Edema
Acute
Subacute
Early
Late
Chronic
Rim
Center
HEMOGLOBIN
Met Hgb in RBC
Free Met Hgb
T2/GRE/SWI
History: 56 y/o woman suddenly
became obtunded
186
History: 57 y/o man with left
hemiparesis after GI surgery
781 - 25799008
Dx: Hypodense CT hgb
RBCs 2.97, HGB 9, Hct 26.5
{Page 2}
History: 78 y/o man with headache,
nausea & gait problem times 3 days
318
Dx: Acute temporal lobe
hemorrhage
Gait problem {Page 2}
History: 43 y/o man with sudden
onset of right face & arm weakness
645
{Page 2}
Dx: Hyperacute hemorrhage
& AVM
{Page 3}
S 34-40
Septic Emboli
and Acute
Hemorrhage
History: 44 y/o male with acute
confusion & lethargy
152
Acute confusion & lethargy {Page 2}
Acute confusion {Page 3}
{Page 4}
Dx: Choroid plexus / ependymal AVM -
Ventricular + thalamic hemorrhage
{Page 5}
History: 59 y/o man with head trauma
& occipital hemorrhage 2 months ago
376
Dx: Subacute-chronic
hemorrhage
{Page 2}
History: 38 y.o. woman
with headache and seizures
Dx: Cavernous angioma
with hemorrhage
History: Seizures
{Page 2}
History: 23 y.o. female with
nausea & dizziness
143
Nausea &
dizziness
{Page 2}
6 week follow-up scan
{Page 3}
143
Dx: Cavernous angioma
with hemorrhage
{Page 4}
History: 62 y.o. female who fell down
and became comatose
109
Dx: Hypertensive hemorrhage
Fall & coma {Page 2}
History: 61 y.o. male with sudden
headache leading to coma
106
Dx: Hypertensive hemorrhage
Headache & coma {Page 2}
History: 38 y.o. woman with sudden onset of
headache, followed by mental confusion
149
Dx: Basal ganglia hemorrhage - Angio (-); Drug abuse history
Increasing lethargy -6 hours later {Page 2}
History: 63 y/o woman with altered mental
status & left hemiparesis
169
Dx: Lobar hypertensive hemorrhage
Hemiparesis {Page 2}
Hypertensive Hemorrhage
Hypertensive patient
Patient 60 or more years old
Basal ganglia or thalamic location
Criteria for Diagnosis
Hypertensive Hemorrhage
Common Locations
Basal ganglia
Thalamus
Brain stem
Cerebellum
Cerebral
hemisphere
50%
5%
10%
10%
25%
History: 45 y/o man with confusion
& lethargy since yesterday
293
Confusion & lethargy
{Page 2}
Lateral View
{Page 3}
Anterior View
Dx: AV malformation with
temporal lobe hemorrhage
{Page 4}
Oblique View
History: 15 y/o girl with sudden headache
followed by loss of consciousness
280
{Page 2}
Dx: Right temporal lobe
hemorrhage with
intraventricular extension;
Rt temporal lobe AVM
{Page 3}
Post 200 PVA
Pre EMBO
AV Malformation
Seizure
Neurological deficit
Compression of normal brain
Vascular steal phenomenon
Hemorrhage
40% bleed by age 40
Usually more benign than
aneurysm rupture
Clinical Presentation
History: 34 y/o woman presented
with chronic headaches
207
Dx: Cavernous angioma
{Page 2}
History: 33 y/o man was beat up in jail
399
{Page 2}
{Page 3}
Head trauma
Dx: Cavernous angiomas
{Page 4}
History: 18 y/o woman with blurry
vision left eye for 2 months
583
{Page 2} GRE
ADC
DWI
B0
Dx: Cavernous angioma
{Page 3}
Cavernous Angioma
Honeycomb of epithelial-lined
vascular spaces separated by
fibrous collagenous bands
No intervening neural tissue
Well-defined; hemosiderin
& calcification often present
Slight enhancement
Angiogram usually negative
Dx: Capillary telangiectasia
Capillary Telangiectasia
Capillary Telangiectasia
Abnormal dilated capillaries separated by
normal neural tissue
Usually in the pons
Occult clinically, angiographically & on CT
MR features
Brush-like hyperintensity on FLAIR and T2
Stippled enhancement pattern
Mild hypointensity on GRE
Any hemorrhage suggests a mixed lesion
History: 16 y/o male was an
unrestrained driver in an MVA
438
Dx: Axonal shear injuries
{Page 2}
History: 28 y.o. male had severe
closed-head injury 6 months ago
94
Trauma {Page 2}
{Page 3}
Dx: Multiple hemorrhagic
contusions - 6th
nerve nucleus
{Page 4}
History: 9 y/o boy with prior head trauma
466
Dx: Multiple brain contusions
& shear injuries (DAI)
{Page 2}
History: Newborn girl with seizures
& decreased alertness
250
{Page 2}
Newborn with seizures
{Page 3}
{Page 4}
Dx: Hemorrhagic infarct with thrombosis
of deep venous system, straight sinus
& right transverse sinus
Day 7
{Page 5}
2 cm to right
History: 15 y.o. girl with flu-like
syndrome and increasing lethargy
History: Lethargy {Page 2}
Dx: SSS thrombosis
History: Lethargy
{Page 3}
History: 60 y.o. female with
a right hemiparesis
11
Hemiparesis {Page 2}
Dx: Hemorrhagic
lacunar infarct
{Page 3}
Hemorrhagic Infarction
Occurs during 1st week
Hallmark of embolic infarction and venous infarction
Anticoagulant therapy
Increased density on CT
Hyperintense on T1 MR image
History: 77 y/o woman
with right-sided weakness
733
{Page 2}
Dx: Amyloid angiopathy
{Page 3}
Amyloid Angiopathy
Deposition of eosinophilic material in media
& adventitia of small arteries & arterioles
Fibrinoid degeneration
Microaneurysmal dilatation
Multiple cortical hemorrhage
Associated with aging & Alzheimer's disease
History: 22 y/o man with acute lymphoblastic leukemia
presents with headache & vomiting
586
Dx: Hemorrhages secondary to
thrombocytopenic purpura
{Page 2}
Hypocoagulable
State
History: 58 y.o. veteran
with left arm weakness
Dx: Glioblastoma
{Page 2}
History: 38 y.o. man with new onset seizures
74
Dx: Metastatic melanoma -
Hemorrhagic
{Page 2}
64
History: 67 y.o. male with visual
problems for 2 weeks
Visual problems
{Page 2}
{Page 3}
Dx: Hemorrhage mets -
Thyroid CA {Page 4}
History: 37 y/o man with headaches & decreased vision
541
{Page 2}
Dx: Hemorrhagic Pituitary
adenoma
{Page 3}
Dx: Pituitary apoplexy
History: 24 y/o female
with a visual deficit
554
Epidural & Subdural
Hemorrhage
History: 28 y.o. woman was found
comatose following an MVA
90
Dx: Acute epidural
hematoma with fracture
Trauma {Page 2}
Extracerebral Hemorrhage
Evolve more slowly
Hemosiderin uncommon
Chronic lesions isointense on T1WIs More dilution from CSF
Breakdown of free methemoglobin
Less resorption of fluid component
Key Differences
History: 62 y/o male found down
confused & disoriented
269
Confused
{Page 2}
Dx: Bilateral subacute
subdural hematomas
{Page 3}
History: 75 y.o. man with mental status change
Dx: Acute hemorrhage into
chronic subdural
hematomas
History: Mental status
change {Page 2}
History: One y/o boy fell out of bed & was
having difficulty moving the right arm
292
Trauma {Page 2}
{Page 3}
FLAIR
{Page 4}
T1WI's
Dx: NAT (non-accidental trauma)
- Multiple SDHs of varying
ages & brain contusions
{Page 5} T2W
FLAIR
GRE
Subarachnoid
Hemorrhage
Subarachnoid Hemorrhage
Conventional MR sequences insensitive
FLAIR good for cortical sulci & posterior fossa
Hemorrhage evolves more slowly
Subacute & chronic SAH not visible due to dilution
Pial siderosis with repeated small hemorrhages
History: 57 y/o female with
acute intracranial hemorrhage
373
Dx: SAH - FLAIR
{Page 2}
History: 50 y/o man with atrial fibrillation,
hearing loss & nystagmus
470
Dx: Pial siderosis
(on coumadin x 10 yrs)
{Page 2}